The Patient's Guide To Hair Restoration

The Patient’s Guide to
Hair Restoration
William R. Rassman, M.D.
Robert M. Bernstein, M.D.
Contributions by
Robert McClellan, M.D., Roy Jones, M.D.,
Marc Pomerantz, M.D., and Richard C. Shiell, M.D.
www.newhair.com 1-800-NEW-HAIR
Copyright © 2005 New Hair Institute, Inc. All rights reserved.
New Hair Institute, Inc., 9911 West Pico Boulevard, Suite 301, Los Angeles, CA 90035

Chapter 1
A Brief History of Hair
Throughout history, hair has been an important symbol. The significance
of hair as an indicator of gender, and social, religious and professional status has
been as great as that of clothing, jewelry, tattoos, weapons, and even crowns.
The importance of hair goes back at least as far as the Neolithic Age. Several
years ago, a man’s body was found frozen in a glacier near the Austrian-Italian
border. Because he looked like modern man, it was first thought that he had died
only a few years before. Upon examination of his clothing and weapons,
archaeologists concluded that he had been frozen for more than 5,000 years. It is
likely that this preserved Neolithic man wore his hair in the fashionable cut and
style of that age. His hair was neatly cut to a length of 3.5 inches, and his beard
was trimmed.
In Ancient Egypt, sons of the Pharaoh wore their hair tied in a distinctive
bun on the right side of the head just behind the ear. The Pharaoh himself was
never seen without a wig. Even today, male and female English judges wear
obviously artificial horsehair wigs when they preside in court.
The oldest known medical text is an Egyptian papyrus scroll. Its remedies
include an ointment for restoring lost hair, consisting of equal parts crocodile fat
and hippopotamus dung. The physician who wrote the text recommended that
one rub this concoction into the bald scalp.
The ancient Greek physician, Hippocrates, recognized a connection
between the sexual organs and baldness. He may have been the first to record
the observation that eunuchs (men castrated before puberty) did not become
bald. Hippocrates' own baldness stimulated his interest in the subject of hair loss.
His prescription for preventing hair loss was the application of a mixture of cumin,
pigeon droppings, horseradish, and nettles to the scalp. In fact, the area of
permanent hair that encircles the back and sides of the head is sometimes
referred to as the Hippocratic wreath.
Dating back to Biblical times, the tale of Samson is one of the familiar
examples of man's concern over hair loss. Samson had the strength to destroy
the Philistines as long as his hair remained long and uncut. As soon as Delilah
cut his hair, he lost all of his strength.
Early Christian monks and priests shaved the hair on the crown of the head to
create a tonsure. This highly visible mark proclaimed their vow of chastity to the
world. It symbolized their lack of concern with worldly vanities and riches; it also
expressed their personal dedication to God. During the Middle Ages, Christian
society saw an emphasis of concern with the spiritual side of life and a studied
neglect of physical functions. The tonsure became so extreme that, upon taking
orders, a monk shaved his head almost completely bare, so that only a narrow
fringe of hair remained encircling his head.
During the time of King Louis XIV of France, elaborate wigs became
fashionable for the aristocracy. Some of these wigs incorporated paraphernalia
such as model ships and cages with live birds. The more complex constructions
often weighed 15-20 pounds. Known for luxuriant hair in his youth, King Louis

began this practice and may have adopted the fashion to disguise his balding as
he grew older. Elaborate wigs continued to be a class status and fashion symbol
until the middle of the eighteenth century.
Hair has also been an important symbol of rank and religion in Asia.
Buddhist monks shaved their heads completely. Japanese Samurai warriors
shaved the front and top of the head and drew the long back and side hair into a
complex topknot. Even modern day Sumo wrestlers wear their hair in a
distinctive knot at the back although they do not shave the front and top. The
ubiquitous queue or pigtail of Chinese men, a long single braid worn down the
back, was a symbol of their bondage to a lord, landowner, or to the Emperor.
Most urban Chinese men cut off their queues after the revolution in 1920, but the
custom persisted in many rural areas. During the revolution, any man found
wearing a queue was publicly humiliated; his hair was cut off and burned.
Today, hair continues to be an important part of self-expression, and can
function as a symbol of attitude, culture, and religion. Hair, or the lack of it, is of
great significance to rock singers, punks, Rastafarians, Hare Krishnas, Orthodox
Jews, Sikhs, Sufis, Buddhists and Hindus. Hair is important to our self-image
and self-identity, and for both men and women, it is a universal symbol of youth.

Chapter 2
Hair and Its Functions
The condition of one’s hair is an important indicator of age and the body’s
general state of health. Other similar indicators, such as skin condition, muscular
coordination, brightness of the eye and alertness of manner, are often more
subtle or may be masked by clothing. Hair, however, is usually in plain sight.
There are associations and social reactions that may result if one’s hair is gray or
a man is bald. It has been thought that such reactions are were based on primal
judgments, such as whether the person is fit for warfare, reproduction, and or
active labor. A full, glossy head of hair is a clear signal that one is youthful,
vigorous, and therefore, desirable.
Hair is composed of a complex protein called keratin. Of the human body’s
three basic compounds: , proteins, fats, and carbohydrates; the synthesis of
protein requires the greatest investment of energy. When a person becomes ill or
malnourished, his/her hair stops growing. When illness or malnutrition is severe
or prolonged, the hair may fall out (the medical term for this is telogen effluvium).
The resumption of hair growth is a sign that recovery has begun. Science
continues to explore why hair grows or fails to grow, and why it falls out in some
people, but not in others.
Mammals share several characteristics. Most mammals bear live offspring (as
opposed to laying eggs) and nurture their young with milk made in special glands
on the female’s body. Mammals are warm-blooded, that is, they maintain
constant body temperature independent of the outside temperature. Hair is a
feature shared by all mammals; and like many mammals, man’s skin is covered
with hair. Human skin has more hair follicles per unit of surface area than the
skin of most other primates; which this is surprising, since as most primates
appear to be so much hairier than humans. This impression is caused by the
greater length and coarseness of the individual hair shafts in primates such as
monkeys and apes. In contrast, the majority of human body hair consists of a
very fine, almost invisible, type of hair called vellus hair.
Human hair is classified into two main types: fine, vellus hair; and the
coarser, more visible terminal hair. Except for the palms of the hands and the
soles of the feet, most of the human body’s areas of seemingly bare skin are
actually covered with very fine vellus hairs that may be almost invisible except to
under very close or microscopic inspection. There are several distinct subtypes
of terminal hair. For example, eyelash hairs, called cilia, are different from head
and body hair. Pubic (groin) and axillary (armpit) hairs are also different from
terminal hairs on the head and are associated with different types of glands in the
skin. Even scalp hairs have several different sub-groupings. For example, there
is a fringe of very fine hair surrounding the circumference of the head. This hair
gives a transitional gradation of thickness from the bare skin appearance of the

vellus hair to the dense, thick hair of the crown. Similarly, the hair above the ears
or at the base of the neck is not as coarse as that of the crown.
The reasons we have hair and the functions of its growth patterns are not
completely understood. Our pre-historic ancestors were much hairier than we are
today; the reason for the decreased hairiness of modern man is unknown,
although it is reasonable to assume that it parallel the use of clothing for warmth
and protection. Hair serves as insulation from the cold; however, this does not
explain why different human groups have distinct patterns of hair growth. Most
people of Asian descent have very sparse body and facial hair, but some of
these peoples such as the Inuit, Tibetans and Mongols people, inhabit some of
the coldest regions on earth. Hair has the additional function of extending the
sensory capability of the skin beyond its surface. Although human hair lacks the
wealth of sensory nerve fibers found at the root of whiskers of some animals,
each hair has a nerve fiber going to the bulb of the hair follicle. Mechanical
displacement of each hair causes a sensation, an awareness of movement. For
example, when an ant or fly walks on one’s arm, one feels the displacement of
hairs caused by the insect.
Hair plays a role in the defense mechanisms of most fur-bearing animals
as well. When an animal confronts a potential enemy, its fur bristles, standing on
end to make the animal appear to be larger and more threatening. In dogs, this
response is most visible in the neck area where the neck hairs, called hackles,
rise. In cats, the most visible response may be in the tail. An extreme example of
the use of hair for self-defense occurs in porcupines: their quills, which are
modified hairs, stand out from the body when the animal feels threatened.
Porcupines have converted a reflex, that in most animals is purely defensive, into
a formidable weapon. In modern man, with relatively sparse body hair, only
vestigial traces of these reactions remain. A separate, tiny muscle connects the
lower portion of each hair shaft with the underside of the skin. When you are
frightened, cold or angry, these small muscles, called erector pili muscles,
contract, causing your hair to stand on end.
Each hair shaft also contains a small gland called the sebaceous gland,
located next to the hair shaft. Sebaceous glands make a yellow, fatty substance
called sebum that lubricates the hair. Each time the erector pili muscle contracts,
the gland is squeezed, and a small amount of lubricant is applied to the surface
of the hair. Hair, along with skin pigmentation, is the major natural protection that
we have against the sun’s harmful ultra-violet rays. Scalp hair also plays an
important role in preventing mechanical trauma to the skull. Hair acts as a "dry
lubricant" in areas that rub, such as under the arms and in the groin, and serves
to disperse pheromones (body secretions that are involved in sexual attraction).
Hair is integral to our body image and can have a profound influence on
our self-esteem and self-confidence. There is no other part of the human
anatomy that can be changed or manipulated so easily. Hair can be groomed,
styled, waved, straightened, dyed, braided, or cut, and, unlike tattoos or body
piercing, changes made to our hair can be completely reversed. Hair serves as a
means of self-expression, and the loss of this form of self-expression in people
who are going bald may account, at least in part, for the despair that they may
experience. For all of its simple appearance, hair is a complex and valuable
organ. Although we usually think of hair only in terms of the visible portion of the

hair shafts, each hair, along with its muscle and sebaceous gland, must be
working properly to maintain a healthy head of hair.
Anatomy & Physiology of Hair
Anatomically, hair is a part of the skin. As hair is physically distinct
however, it is among the structures known as skin appendages. Other skin
appendages include sweat glands, fingernails and toenails. Skin is composed of
three main layers. The outer layer of skin is the epidermis. This layer is less than
a millimeter in thickness and is composed of dead cells that are in a constant
state of sloughing and replacement. As dead cells are lost, new ones from the
growing layer below replace them. Beneath the epidermis is the dermis, a tough
layer of connective tissue that is about 2 to 3 mm thick on the scalp. This layer
gives the skin its strength, and contains both sebaceous glands and sweat
glands. Beneath the dermis is a layer of subcutaneous fat and connective tissue.
The larger sensory nerve branches and the blood vessels that nourish the
skin run deep into this layer. In the scalp, the lower portions of the hair follicles
(the bulbs) are found in the upper part of this fatty layer. The hair follicle
measures about 3-4 mm in length and produces one to four hair shafts, each
about 0.1 mm in width. It is a complex structure comprised of three main layers.
The outer layer, called the outer root sheath or trichelemma, surrounds the
follicle in the dermis and then blends into the epidermis on the surface of the
skin, forming the structure commonly referred to as the pore (from which the hair
emerges).
The middle layer, the inner root sheath, is composed of three parts
(Huxley layer, Henly layer, and cuticle), with the cuticle being the innermost
portion that touches the hair shaft. Interestingly, the cuticle is formed by a layer of
overlapping cells that interlock with the cuticle of the hair shafts shaft (matrix
cells). This mechanism holds the hair shaft securely in place, but also allows it to
grow in length.
The hair shaft itself is also composed of three layers. The cuticle, the outer layer
just described, forms the surface of the hair and is what we see as the hair shaft
emerges from the follicle. The middle layer, the cortex comprises the bulk of the
hair shaft and is what gives hair its strength. It is composed of an organic protein
called keratin, the same material that comprises rhinoceros horn and deer
antlers. The center, or core, of the hair shaft, is the medulla, and is only present
in terminal hair follicles. The lower portion of each hair follicle widens into a
region called the bulb, which contains the matrix cells. The size of the bulb and
the number of matrix cells will determine the width of the fully-grown hair.
Below each follicle is a small, collection of specialized cells, called the
dermal papillae. The dermal papillae fit into a hollow in the widened base of the
hair shaft. For many years, scientists thought that hair growth originated from the
dermal papillae. Recent evidence has shown that the growth center extends from
the dermal papillae all the way up to the region of the follicle where the
sebaceous glands are attached. It is now believed that the primary function of
the dermal papillae is to regulate follicular growth and differentiation. If the
dermal papillae are removed (this sometimes happens during a hair transplant),

the hair follicle is able to regenerate a new one, although the growth of the new
hair will be delayed.
The normal human scalp contains about 100,000-150,000 follicles that
produce thick terminal hair. For comparison, the human body has approximately
5 million follicles that produce the fine, vellus hair. At any given time, about 90%
of terminal hairs on one’s head are actively growing. This phase, called anagen,
can last from 2-7 years, though the average is about three. Scalp hair grows at a
rate of about 0.44 mm/day (or 1/2 inch per month). The other remaining 10% of
scalp hairs are in a resting state called telogen that, in a normal scalp, lasts
about three months. When a hair enters its resting phase, growth stops, the bulb
detaches from the papilla, and the shaft is either pulled out (as when combing
one’s hair) or pushed out when the new shaft starts to grow. When a hair is
pulled out, or falls out on its own, a small, white swelling is found at the bottom of
the hair shaft. Most people assume that this is the growth center of the hair, but it
is just the clubbed, detached lower end of the hair shaft. The dermal papillae
remain in the scalp.
Humans lose about 100 hairs per day; everyone has a few hairs stuck to
the comb each time they comb their hair. The presence of a large number of
hairs on the comb, in the sink, or in the tub can be the first sign of excessive hair
loss. One of the most interesting things about hair is that, in contrast to the
commonly held notion that it grows as individual strands, it actually emerges from
the scalp in groups of one to four (and sometimes even five or six). The reason
for this is that hair follicles are not solitary structures, but are arranged in the skin
in naturally occurring groups called follicular units. Although skin pathologists
recognized this fact in the early 1980's, its profound importance in hair
transplantation surgery was not appreciated until the mid-1990’s. The use of
naturally occurring, individual follicular units has revolutionized modern hair
transplantation.

Chapter 3
The Causes of Hair Loss
Facts
All humans are born with a finite number of hair follicles. The diameters of
the individual hairs in our follicles increase as we grow from infancy to adulthood.
However, no matter what we eat, what our lifestyles may be, or what kinds of
vitamins we take, we never grow any more hair follicles.
At puberty, men have a very low hairline that usually recedes to its mature
position by the age of 20 to 22 and then stabilizes. In men with a genetic
tendency to go bald, this hairline will continue to recede. Severe illness,
malnutrition, or vitamin deficiency can speed or exacerbate the natural hair loss
process, but many healthy men lose more hair than others do. This natural
process is called androgenetic alopecia or common baldness (also known as
male pattern baldness). It is only in recent years, with our greater knowledge of
genetics and the chemistry of sex hormones, that we have begun to understand
the causes. It is important to note that male pattern baldness also occurs in
women, but in a slightly different form.
Androgenetic alopecia or male pattern baldness is a process that changes
the follicles that produce terminal hairs. Follicles first produce thinner, shorter
hairs with weaker shafts. Eventually, these follicles produce only fine, almost
invisible, vellus hairs, and they may die out altogether. Androgenetic alopecia
requires three conditions for its occurrence: the genes for hair loss, male
hormones in adequate quantities, and time.
Genes
A gene is a single bit of chemically encoded hereditary instruction that is
located on a chromosome and represents a tiny segment of DNA. Chromosomes
occur in pairs (humans have 23 pairs), and every individual inherits one set of
chromosomes from each parent. The genetics of androgenetic alopecia is
complicated and hair loss is thought to involve more than one gene. When
several genes govern a trait, it is called polygenic. Genes that are located on the
X- or Y-chromosomes are call sex-linked. Genes on the other 22 pairs of
chromosomes are called autosomal. It is currently believed that the genes
governing common baldness are autosomal. This means that the baldness trait
can be inherited from the mother’s or the father’s side of the family. The
commonly held notion that baldness comes only from the mother’s side of the
family is incorrect, although for reasons not fully understood, the predisposition
inherited from an affected mother is of slightly greater importance than that
inherited from an affected father. The term "dominant" means that only one gene
of a pair is needed for the trait to show up in the individual. A "recessive" gene
means that both genes must be present in order for the trait to be expressed.
The genes involved in androgenetic alopecia are believed to be dominant.
Just because a person has the genes for baldness does not mean the trait
will manifest itself. The ability of a gene to affect one’s characteristics, i.e. be

visible in a particular individual, is called "expressivity." Expressivity relates to a
number of factors, the major ones being hormones and age, although stress and
other factors may play a role. To put it simply, a man whose father and uncles
are severely bald may have minimal hair loss himself because the expression of
the baldness gene is limited.
None of the genes responsible for male pattern baldness has yet been
identified. This suggests that any kind of genetic engineering to prevent common
baldness is still many years away.
Hormones
Hormones are biochemical substances produced by various glands
throughout the body. These glands secrete their products directly into the
bloodstream in order to spread them throughout the body. These chemicals are
very powerful and minute amounts of them have profound effects upon the body.
The primary male sex hormone is testosterone. Testosterone and other
related hormones that have masculinizing effects are produced primarily in the
testicles. This means that the hormonal levels that are seen in adults do not
reached significant levels until the testicles develop and enlarge during puberty.
These same hormones are the cause of many changes that occur in puberty:
deepening of the voice, growth of facial hair, development of body odor, change
in the muscular development, and change in body shape. These hormones that
cause acne and beard growth can also signal the beginning of baldness. The
presence of androgens, testosterone, and its related hormone DHT, cause some
follicles to regress and die. In addition to the testicles, the adrenal glands located
above each of our kidneys, produce androgenic hormones; this is true for both
sexes. In females, ovaries, like testicles, are a source of hormones that can
affect hair.
The relationship between a man’s testicles and hair loss has been
recognized for centuries. In societies that had harems, guards were castrated to
prevent sexual activity between the guards and women of the harem. In all of
those societies, it was observed that men who were castrated before puberty did
not become bald. Early in the 20th century, castration was common among
patients with certain types of mental illness. Castration seemed to have a
calming effect, and noticeably reduced sex drive in patients. A psychiatrist
discovered the specific relationship between testosterone and hormonally
induced hair loss during this time. The doctor noted that the identical twin
brother of one patient was profoundly bald while the mentally ill twin had a full
head of hair. The doctor decided to determine the effect of treating his patient
with testosterone, which had recently become available as a drug. He injected
his patient, the hairy twin, with testosterone to see what would happen. Within
weeks, the hairy twin began to lose all but his wreath of permanent hair, just like
his normal twin. The doctor stopped administrating testosterone; however, his
patient never regained his full head of hair.
The hormone believed to be most directly involved in androgenetic
alopecia is dihydrotestosterone (DHT). DHT is formed by the action of the
enzyme 5-a reductase on testosterone. DHT acts by binding to special receptor
sites on the cells of hair follicles to cause the specific changes associated with
balding. Among other effects, DHT decreases the length of the anagen

(growing) cycle, and increases the telogen (resting) phase, so that with each new
cycle the hair shaft becomes progressively smaller.
In men, 5-a reductase activity is higher in the balding area. Women have
half the amount of 5-a reductase overall as compared to men, but have higher
levels of the enzyme aromatase, especially in their frontal hairlines. Aromatase
decreases the formation of DHT, and its presence in women may help to explain
why female hair loss is somewhat different than hair loss in males.
Time
The mere presence of the necessary genes and hormones is insufficient
to cause baldness. Hair loss also requires exposure of susceptible hair follicles to
the responsible hormones. The time required for hair loss to start due to hormone
exposure varies from one individual to another, and relates to a person’s
genetic expression and to the levels of testosterone and DHT in his bloodstream.
Significantly, hair loss does not occur all at once, but is cyclical. People who are
losing their hair experience alternating periods of slow hair loss, rapid hair loss,
and even stability (no increase in hair loss). The factors that cause the rate of
loss to speed up or slow down are unknown.
Stress
When the body experiences stress caused by a traumatic experience,
nutritional deficiency, or illness, the rate of hair loss can increase. An example of
this occurred in a man whose four-year-old child died. Within just a few months,
he lost all but the permanent wreath of hair around his head.
Women's hair seems to be more sensitive to the effects of stress than
men's hair. This may be because women with a genetic predisposition towards
hair loss usually have a higher percentage of fragile miniaturized hair. It is
important to note that stress generally causes the type of hair loss referred to as
telogen effluvium. This is very different from androgenetic alopecia. Telogen
effluvium is the reversible shedding of hair in the resting phase when the body
senses that it needs to divert its energies elsewhere. Therefore, stress
temporarily changes the amount of hair that is shed, but the lost hair is likely to
grow back.
Fiction
Lack of Blood Supply
Some assert that a lack of blood supply contributes to hair loss. Bald skin
gradually loses some of its blood supply and, consequently, it becomes thin and
shiny. These changes, however, are secondary to the loss of hair. Hair follicles
are one of the most rapidly metabolizing tissues in the body; their high metabolic
rate demands an excellent blood supply to carry oxygen and other nutrients to
the cells. If the blood supply diminishes, the follicle cells wither and die. Growing
hair requires the proper nutrition that comes with a good blood supply. When hair
follicles are transplanted into skin grafts or scar tissue, both of which have a
relatively poor blood supply, the presence of the grafted hair causes the local
blood supply to increase.

Clogged Pores
This claim usually accompanies microscopic photographs of an empty
follicle clogged with a heaped up waxy substance that prevented the hair from
growing. There is no scientific evidence that clogged pores could interfere with
hair growth. Common sense is sufficient to refute these claims. Why would pores
be clogged on the top of the scalp and not on the back and sides? In addition,
everyone has had an ingrown hair at one time or another. An ingrown hair occurs
when a hair grows through intact skin where there is no opening. If a hair can
force its way through skin, it can certainly grow through soft, waxy sebum at the
bottom of an empty follicle. It is also important to note that the lubricants that
normally coat the surface of the hair shaft are produced even when a hair shaft
falls out. Since there is no hair shaft surface for these lubricants to coat, they pile
up in the bottom of the follicle space. If clogged pores caused baldness, women
would be as bald as men.
Lack of Air Circulation to the Head
Folklore says that men who constantly wear hats are more likely to
become bald, as hats prevent air from circulating to the head. Hair follicles get
their oxygen through the bloodstream, however, rather than from ambient air.
Factors that affect only the exposed part of the hair do not injure the growing
portion of the hair root. One exception to this is that constant traction on the hair
follicles, such as from the continuous wearing of "corn rows" or very tight braids,
can cause permanent hair loss. This condition is called traction alopecia, and is
distinct from androgenetic alopecia.
Preventing Hair Loss
Many over-the-counter lotions and drugs claim to restore lost hair.
Whether sold through drug stores, salons or mass media, most are useless. A
1989 Supreme Court decision prevents these potions from being advertised or
sold in the United States as medications that prevent hair loss or promote the re-growth
of lost hair; however, such claims are still made. Charlatans of every
age have eagerly seized upon each new scientific wonder to profit from a gullible
public. Excepting cancer and arthritis, hair restoration has been one of the most
fertile areas for medical nostrums. For example, in the same year that the
principle of the magnetic field was described, "magnetic" and "electric"
hairbrushes for the prevention and treatment of baldness appeared on the
market. Concoctions that claimed to be "snake oils" were also sold for the
treatment of arthritis and baldness. In hindsight, it is understandable that an
unsophisticated person, who was crippled by pain from arthritis and who lived at
a time when there was no better treatment for his illness, might be desperate
enough to try "snake oil" as a treatment for arthritis. However, until the Supreme
Court decision banning their promotion, ads for products that claimed to be able
to restore hair filled the television airwaves. Infomercials complete with real
doctors, pictures, and testimonials promoted these worthless potions every day.
Even today, it is difficult for the layperson to differentiate between fact and fiction

when it comes to hair loss remedies. There are two FDA approved medications
to treat androgenetic alopecia. Though they have limited benefit, they may be
useful for many. These two medications, minoxidil and finasteride, are discussed
in detail in the chapter titled "Drugs to Prevent Hair Loss."

Chapter 4
How Bald Will I Be?
For most men, the first sign of excessive hair loss is the appearance of
more hairs than usual on their comb or brush. Some men first notice excess hair
at the bottom of the bathtub or on their fingers after shampooing. Men who are
going to lose a very large amount of hair usually see the first signs between the
ages of 17 and 25. Men whose fathers or grandfathers on either side of the
family were bald, will probably notice the hair loss before someone who has no
apparent family history of baldness. Sensitized to the possibility of hair loss, they
are waiting for the process to begin.
As soon as he notices any sign of excess hair loss, the typical man will
rush to a mirror to do a hair-by-hair inspection of his frontal hairline. If he cannot
see any sign of hair loss, he may compare his present hairline with one from a
recent photo. He will continue to closely observe his hairline every day. He will
also attempt to keep, a hair-by-hair count of the hair on his comb, his fingers, or
in the tub. Dark-haired men notice the hair loss process earlier that light-haired
men do.
Some men resort to potions, regimens, or shampoos. A good shampoo
will clean your hair, but no shampoo will stop the balding process. These
approaches may offer the comfort of doing something during the early phase of
hair loss, but eventually the futility of these measures will become obvious.
What can a man do? How can he cope with the disintegration of his
youthful looks? What will he look like without hair? How will this affect his ability
to attract a partner? How will his professional life be affected? Will the change
affect his ability to gain a promotion? Will his ability to sell his product line to
clients be affected? Anything that erodes self-confidence can have a negative
effect upon all aspects of life.
The first step is to make an assessment of the extent of hair loss. One way to do
this is to compare your present hairline with your hairline in a recent photograph.
This will give you an approximation of the amount and rate of your hair loss. An
unknown factor for most men is the extent of hair loss in the crown area. Looking
in a mirror is one way to appraise the loss at the back of your head. The best way
to accurately assess the hair loss in this area is to have a photo taken of the back
of your head. For an accurate reading, the picture must be taken with a flash.
Almost every man who has significant loss in this area is surprised by the results.
Another way is to ask your significant other, barber or hairdresser.
If hair loss is bothering you, a visit to a physician who specializes in hair
restoration is a worthwhile step. A thorough medical history and examination of
the scalp can reveal the extent and trends of your hair loss. With the use of
special magnifying apparatuses, a physician can specifically measure the degree
of hair loss in various areas of the scalp. This establishes a baseline from which
your hair loss can be graded over time. If you decide to treat your hair loss with
minoxidil or finasteride, a repeat examination in 6-12 months may show the

effectiveness of the treatment. Careful assessment of hair loss is critical to
accurate prediction of the rate and extent of future hair loss.
Once you have confirmed your hair loss, you should compare your degree
of baldness with the standard charts that follow. These charts have been adapted
from the patterns described by Dr. O'Tar Norwood. They depict the most
common configurations of male pattern baldness. There are seven grades of
hair loss in the main series and five grades of a variation called the A series.
Comparing the front and back of your scalp with these diagrams can tell you
where you stand now. Discussion with a knowledgeable physician can give you
an idea of future hair loss.
The next step is to decide whether to accept your hair loss or take
measures to stop or reverse the process. If you are less than 45 years old, you
might consider using minoxidil or seeing a doctor for a prescription for finasteride.
One option is to obtain a hairpiece. Another option is to replace lost hair with your
own natural, permanent hair via hair transplant surgery.

Chapter 5
Drugs to Prevent Hair Loss
For years, worthless hair potions have been sold to men to rub on their
balding scalps. Finally, two effective medications exist for the treatment of hair
loss.
Minoxidil (Rogaine)
Minoxidil, as an oral medication, has been available for a number of years
for the treatment of high blood pressure. Because of its serious side effects on
the heart and general circulation, it is only used with patients unsuccessfully
treated with the maximum doses of other drugs. During its use as a treatment for
high blood pressure, it was observed that some patients who were taking
minoxidil began growing hair in unusual areas of the body, such as the forehead
and on the backs of their hands. It was thought that applying minoxidil directly to
a bald scalp might cause hair growth in that area. If hair growth occurred without
other side effects, then it might be useful to healthy balding men. It was then
proven that when a topical solution of minoxidil was applied to bald scalps, some
men grew hair in the areas where it was applied.
Rogaine, manufactured by Pharmacia & Upjohn Inc., is the brand name
for the topically applied minoxidil solution. It can be purchased without a
prescription in either 2% or 4% concentrations. Although the mechanism that
causes minoxidil to stimulate hair growth is not known, it probably works by
prolonging the hair follicle growth cycle. Controlled studies on minoxidil show that
it only grows hair in the vertex (back part) of a man’s scalp, and only in areas that
are not completely bald. It does not usually re-grow hair in the front part of a bald
scalp.
It appears that minoxidil's effects may only be temporary. Since
testosterone is always present in the blood stream, this hormone eventually
overcomes the effects of the minoxidil so that over time, men using minoxidil
continue to bald, although at a somewhat slower rate. The concomitant use of
minoxidil and finasteride (see next section) may circumvent this problem, as
there is evidence that in some cases these drugs may act synergistically.
Before trying minoxidil, be aware that it may take 6-12 months before
results start to appear. In addition, unless the medication is used consistently
twice a day, it will not be effective. For most men, minoxidil does not grow any
significant amount of new hair. The primary action of minoxidil is to thicken
already existing hair that has thinned or miniaturized, and most patients who do
grow hair, grow only short, thin fuzz.
The majority of patients who experience benefits from minoxidil see only a
delay or decrease in hair loss. For many men, the effects are first noticed when
they stop using the medication. Once the drug use is stopped, the previous
pattern of hair loss resumes, and any positive effects are lost within two to three
months, even if the medication had been used for many years. This same
limitation applies to other drugs used for hair loss.

Many patients are attracted to minoxidil because of its seeming lower cost
compared to other methods of hair replacement. However, because the effects of
minoxidil are temporary, the lifetime cost of using minoxidil can be more
expensive than the cost of hairpieces or surgical treatments for hair loss.
Minoxidil is often prescribed in conjunction with other medications such as
topical retinoic acid (Retin-A) to increase its topical penetration. These
medications can greatly increase the systemic absorption of minoxidil and may
increase the risk of potential side effects, including severe scalp irritation. The
prescribing information provided by Upjohn specifically states Rogaine should not
be used with other topical agents including topical corticosteroids, retinoids,
petrolatum and/or other agents that are known to enhance drug absorption. One
should not use Rogaine if one's scalp is sunburned or becomes irritated.
A problem unique to patients using the combined mixture of
minoxidil/Retin-A occurs when scalp irritation begins and the patient is afraid to
stop the Retin-A since this would also mean discontinuation of the minoxidil (and
the likely outcome of subsequent hair loss). These patients often continue the
mixture in spite of the development of severe scalp irritation. This can result in
infection, scarring and permanent hair loss.
The early studies with minoxidil were on balding men, but it appears that
minoxidil may actually be more effective for women experiencing hair loss. This
is probably because women usually exhibit diffuse hair loss. Minoxidil, then,
would not be applied to bald areas, but in areas of thinning. Some doctors
recommend minoxidil before and after hair transplantation to decrease or prevent
the temporary loss of hair that sometimes occurs with newly placed grafts,
however, this use has not yet been proven to be reliably effective.
Finally, although it seems that the topical preparation of minoxidil is
innocuous, the long-term safety unknown. As with many medications, the clinical
trials with minoxidil occurred over a very limited period of time. Since the
medication must be continued for years, we may presently be unaware of
potential long-term problems.
Finasteride (Propecia)
Propecia is an oral medication, manufactured by Merck, that blocks the
conversion of testosterone to dihydrotestosterone (DHT), the hormone largely
responsible for male pattern baldness. It does this by inhibiting the action of the
type II 5-alpha reductase enzyme that is present in higher concentrations in and
around the hair follicles of balding men with androgenetic alopecia.
Finasteride causes significant drops in both scalp and blood levels of DHT.
Its effectiveness is believed to be related to both of these factors. In patients
taking finasteride 1-mg/day, serum DHT levels decreased by 68.4%. Serum
testosterone levels actually increased by 9.1% but remained within the normal
range.
Finasteride was originally marketed for use in prostate enlargement in
men over 50 (the prostate also has the type II enzyme). This medication, in a 5-
mg per day dose, is sold under the name Proscar. In the treatment of prostate
problems, finasteride 5-mg has produced breast tenderness and breast
enlargement. It has also caused impotence and decreased sexual interest in a
small number of men.

In January 1998, the FDA approved finasteride 1-mg/day (Propecia) for
the treatment of male pattern baldness. The phase III human trials, using the 1-
mg dose, involved 1,553 men, ages 18 to 41, with Class II Vertex, III Vertex, IV
or V balding patterns, i.e. men with mild to moderate hair loss. After two years,
results showed that 83% of the men taking finasteride either kept their hair or
grew more, while only 17% continued to lose hair. In the crown, 30% showed
slight improvement, 31% showed moderate improvement and 5% showed great
improvement. In the front, 38% showed slight improvement, 4% showed
moderate improvement, and none great improvement.
Hair counts showed an average gain of 86 hairs in a one-inch circle at the
end of one year. These hairs were significantly larger than the fine, miniaturized
hair seen in balding, but they did not necessarily assume the full weight and
diameter of the patient’s original hair.
Sexual Dysfunction
Although uncommon, there can be side effects from finasteride at the 1-
mg dose. At least one study has shown that these side effects include
decreased libido (1.8%), impotence (1.3%), and decreased volume of ejaculate
(1.2%). It is important to note that there was a small incidence of these problems
in the control group as well. Altogether, 3.8% of men taking finasteride 1-mg
experienced some form of sexual dysfunction versus 2.1% in men treated with a
placebo.
Most reported cases of sexual dysfunction occurred soon after starting the
medication, but there have been reports of sexual dysfunction that have occurred
at later points in time. The sexual side effects were reversed in all men who
discontinued therapy, and in 58% of those who continued treatment. When the
medication was stopped, side effects generally went away within weeks, but
occasionally took longer.
If sexual side effects occur, they generally begin well before finasteride
has had a chance to visibly effect hair growth. Therefore, men who experience
side effects can discontinue the Propecia at this time without losing any
additional hair. Like minoxidil, when finasteride is discontinued, one loses the
hair gained or preserved by the medication, not more. In effect, the patient
returns to the level of balding that would have been had he never used the
drugs in the first place.
Gynecomastia
Adverse reactions related to the breast, including breast tenderness or
enlargement (gynecomastia), occurred in 0.4% of men taking finasteride 1-mg
(Propecia), but this was no greater than in the control group. Breast enlargement
in patients taking finasteride may be due to its ability to block the conversion of
testosterone to DHT. This, in turn, may cause more testosterone to be converted
to estrogen, with estrogen then stimulating breast tissue. There have been a few
cases of breast cancer in patients on the 5-mg dose, but a causative relationship
with finasteride has not been established.
Effects on PSA

Finasteride causes an approximate 1/3 decrease in serum PSA (prostate
specific antigen) in normal men. It may also blunt the rise of PSA levels in
patients with prostate enlargement and in patients who have developed prostate
cancer. Since PSA is used to screen for prostate cancer, there is concern that
the use of Propecia may interfere with the detection of this disease. It is
important that you make your personal physician aware that you are taking
finasteride so that he or she can take into account any effects that finasteride
may have on your PSA.
There has been one small study that suggested that finasteride at 5-mg
may increase the risk of prostatic carcinoma in older patients who have an
already significantly elevated PSA. However, the methodology of this study has
been seriously questioned and data from other studies do not support its
conclusion.
Teratogenecity in Women
Finasteride should not be taken by women of childbearing age as birth
defects in male offspring can occur if significant amounts of the drug are
absorbed during fetal development. Pregnant women are warned not to handle
crushed tablets, as the drug may harm the male fetus. However, to our
knowledge, there has not been a single reported case of birth defects caused by
women handling broken or crushed finasteride tablets. The concern over
handling crushed tablets may stem from the FDA policy, which assumes
maximum absorption of the medication during any contact.
There is no evidence that exposure of pregnant women to finasteride via
semen is a risk to the fetus. For those patients who wish to limit any potential
contact of Finasteride, a condom can be worn during intercourse with a pregnant
partner.
Use in Post-Menopausal Women
A recent study was conducted to evaluate the efficacy of finasteride in
post-menopausal women. After one year of use, there was no increased hair
growth and the progression of thinning was not slowed. It is possible that the
low DHT levels observed in post-menopausal women are responsible for the lack
of significant response to finasteride, or that hair loss in this group is not related
to androgens as all. The safety profile for the use of finasteride in post-menopausal
women has not yet been established.
Long-Term Benefits and Risks
The effects of finasteride are confined to areas of the scalp that are
thinning, but where there is still some hair present. Finasteride does not seem to
grow hair in completely bald areas. Therefore, the major benefit of finasteride
seems to be in its ability to slow down or halt hair loss, or re-grow hair in parts of
the scalp where the hair is thin. The long-term ability of finasteride to maintain
one’s hair is unknown. Results generally peak at one to two years and then
decrease slightly after that.
The benefits of finasteride will stop if the medication is discontinued. Over
the 2-6 months following discontinuation, the hair loss pattern will generally
return to where it would have been if the medication had never been used.

Finasteride has now been in clinical use for almost 10 years. The small,
but real, incidence of adverse reactions seen with finasteride underscores the
fact that its actions are not entirely specific or fully understood. Only very long-term
experience with this medication will determine all of its potential effects.
Finasteride and Hair Transplantation
Finasteride can be a useful adjunct to surgical hair restoration for a number
of reasons. Finasteride works best in the younger patient who may not yet be a
candidate for hair transplantation. It is also less effective in the front part of the
scalp, the area where surgical hair restoration can offer the greatest cosmetic
improvement. It can regrow, or stabilize hair loss in the back part of the scalp
where hair transplantation may not always be indicated.
If finasteride is proven safe and effective in the very long-term, it will allow
the hair restoration surgeon to create more density in the most cosmetically
important areas (such as the front part of the scalp), since keeping reserves for
future hair loss in other areas will be less of a concern.
Patient Monitoring
It is recommended that men age 50 or over, should consult with their
regular physician or urologist before using finasteride. It is also recommended
that all men age 50 or over have a routine annual evaluation for prostate disease,
regardless of whether finasteride is used. For those patients who are black
and/or who have a family history of prostate disease, these recommendations
would apply beginning at age 40. An evaluation may include a rectal
examination, a baseline PSA test, and other exams that your physician feels are
appropriate.

Chapter 6
What is a Hair Transplant?
The basic concept of hair transplantation is straightforward and easily
understood. The hair growing on the sides and lower part of the back of the
head is permanent in most people. It persists even in advanced degrees of male
pattern baldness because follicles in these locations are not subject to the
deleterious affects of the hormone DHT, a byproduct of testosterone. The
characteristics of the individual follicles move with them when they are
transplanted. Therefore, permanent hair will remain permanent regardless of
where it is transplanted, a phenomena termed “donor dominance.” This is the
basis of hair transplantation.
In the process of hair restoration surgery, permanent hair is redistributed
to cover the areas of the head where the hair has thinned or has been lost. No
new hair is actually created; existing hair is just moved around. Therefore, there
is never a “net” increase in total hair volume. In spite of this, a skillfully
performed hair transplant procedure can make a person “look” as though he or
she has more hair, often considerably more.
The process of hair restoration is an aesthetic exercise as well as a
technical feat. Re-distributing hair on a person’s head is like painting a portrait.
The physician should attempt to create a natural looking result that is consistent
with the hair supply, the specific hair characteristics of the patient, and most
important, the patient's goals.
As with other forms of cosmetic surgery, the art is at least as important as the
surgical technique. The hair transplant surgeon must have a thorough
understanding of human facial anatomy; good basic surgical skills and a
thorough knowledge of different hair transplant techniques. The physician must
know the physiology of hair in depth, and understand basic medical conditions
that affect the scalp. He must be aware of, and be able to critically evaluate, new
developments in the field. Finally, the specialist must study each patient carefully
and tailor each procedure to the patient's unique attributes and needs.
History
Transplantation of portions of hair-bearing skin from either animals or
humans has been done with varying degrees of success since the early 1800’s.
However, significant modern developments in hair transplantation did not occur
until the next century. In 1939, a Japanese dermatologist named Okuda first
described the punch technique of hair transplantation. Dr. Okuda, working on
severe burn patients, transplanted round grafts of skin containing hair follicles
from the permanent hair-bearing areas into slightly smaller round openings in
scarred areas of scalp. The grafts continued to produce hair in their new
locations. In 1943, another Japanese dermatologist, Dr. Tamura, used 1-3 hair
micrografts to restore female pubic hair. These very small micro-grafts were
obtained from a single elliptical incision taken from the donor area. Interestingly,
his techniques were very similar to those we are using today. The work of both

of these physicians were published in Japanese medical journals, but their
pioneering procedures remained unknown to the Western World because of
World War II.
Hair transplantation was rediscovered by Dr. Norman Orentreich in New
York City in 1952, where he performed the first hair transplant for male pattern
alopecia. In 1959, Dr. Orentreich published his work in the Annals of the New
York Academy of Science (after several years of rejection by a disbelieving
medical community). In this publication he put forth his theory of “donor
dominance” and this began the “modern” era of hair transplantation.
Unfortunately, his work paralleled the “punch” technique of Okuda, rather than
the “micrograft” technique of Tamura and so, by the 1960’s, hair restoration
surgery in the United States was off and running, but in the wrong direction.
What is a Hair Graft?
During hair transplant surgery, small grafts of skin containing hair follicles
are removed from the areas of permanent hair in the back and on the sides of the
head, and moved to the areas where balding or thinning occurs. The grafts are
placed into openings created in the bald area where hair is desired. The
openings can be slits (incisions where tissue is not removed), a punch hole, or
laser hole (where recipient tissue is actually removed or destroyed). Both the
size of the grafts and the size of the wounds where they are placed have
become smaller over the past 40 years. This decrease in size has made the
transplants dramatically more natural in appearance.
The way the transplanted hair follicle behaves differs from most other
“organ” transplants. When kidney, heart or liver transplants are performed, the
person receiving the transplant must remain on powerful immune suppressing
medications to prevent rejection, as the organs are generally transplanted from
one person to another. Since a hair transplant is an “autograft,” (a transplant
from one part of the body to another) there is no rejection and no medications are
required.
Different Graft Sizes
Hair grafts are divided into four general categories: traditional standard
grafts, minigrafts, micrografts, and follicular unit grafts. Traditional standard
grafts are 3-4 mm in diameter and have 12-30 hairs per graft. Minigrafts are
smaller, 1.2-2.5 mm in diameter, and have 4-12 hairs per graft. Micrografts are
even smaller measuring 1.5-1.0 mm or less in diameter, with 1-3 hairs per graft.
Follicular units are the naturally growing groups of hair follicles. Each follicular
unit graft contains 1-4 hair follicles.
Although minigrafts and micrografts are a significant improvement over the
larger grafts, they are not ideal. The idea was reasonable: to keep the number of
hairs in each graft low. However, mini-micrografts were moved in unnatural
arrangements and the naturally growing groups of hair were ignored. This is
because in minigrafting and micrografting, the donor hair is harvested with a
multi-bladed knife. This instrument that breaks up naturally occurring follicular
units and causes unavoidable damage to follicles. Focusing on the number of
hairs, rather than the naturally growing groups, minigrafting and micrografting
damage the follicles, causing a significant transplant failure rate. Micrografts tend

to produce a thin look when used exclusively over the entire head, and often
produce inconsistent graft growth.
Follicular unit grafts are based upon the observation that hair emerges from the
scalp in naturally occurring clusters called follicular units. Each follicular unit is
comprised of one to four terminal hairs. By using the follicular unit as the base
unit of the transplant, the surgeon can create hair patterns that mimic the way
hair grows naturally. The art of the follicular unit approach is that the
characteristics of the patient’s hair dictate the size of the implant (rather than the
doctor). The surgeon determines distribution and balance. By preserving both the
natural physiologic and aesthetic elements of human hair, the best cosmetic
results can be achieved.
There are many advantages of Follicular Unit Transplantation over
micrografting. A fuller look is achieved, as the grafts can be of the same size (or
even smaller) than micrografts yet contain more hair. Graft growth is more
consistent than when the follicular units are split up. Recipient wounds heal
more quickly because sites in the recipient area are smaller, and the results look
more natural. Follicular unit transplantation allows the doctor to distribute grafts
to mimic the way hair grows naturally in the patient’s own scalp.
Follicular Unit Transplantation enables the surgeon to restore more hair
using a smaller amount of donor tissue, as the technique is more efficient than
minigrafting and micrografting. The tissue between the follicular groups is
dissected away, while the vital support structures around the unit are preserved.
Cobblestoning (irregularities in the surface of the scalp) and depigmentation (the
appearance of whitish blemishes of the transplanted skin) can be avoided
because excess skin in the grafts has been removed, making the grafts
significantly smaller. The follicular units produce very small physiologic implants,
that can, in turn, be inserted into very small sites. In addition, larger amounts of
hair may be safely moved in one session reducing the necessity for multiple
procedures. The patient benefits significantly with less time devoted to
restoration, fewer procedures and, often, a lower cost per graft.
The large plugs used in the past, transplanted far too much bald skin in
each graft. Minigrafts and micrografts also consist of multiple (partial or
complete) follicular units along with the intervening skin. Even micrografts
containing as few as two or three hairs may contain unnecessary skin if the hair
was taken from two or more separate follicular units. Hair moved in these types
of grafts results in transplanted tissue that has the same ratio of follicles to skin
as the donor area. As healing occurs, the scar around the graft contracts,
pushing the hairs in the graft together, and the density of the hair within the graft
increases. The hair density within these larger grafts often exceeds the hair
density in the donor area. This higher hair density within grafts is intrinsic to the
principles of scar contraction, and produces the pluggy appearance of traditional
grafts.
There are other problems associated with the use of the larger grafts. It
takes four to six days for the buds of new capillary blood vessels to grow into the
grafts from the surrounding tissue. Until these new blood vessels grow into the
grafts, the graft’s cells depend upon the surrounding tissue fluid seeping into
them to bring them oxygen and nutrients. Hair follicle cells have a very high
metabolic rate, and they require more oxygen and other nutrients than other

cells. If the graft is too large, the cells of the follicles in the center of the graft may
die before sufficient oxygen and nutrients can reach the center of the graft. The
follicles at the periphery of the graft survive because they receive sufficient
oxygen. When hair finally grows from these larger grafts, it has a doughnut
configuration, with hair at the edges and a bald central area. This is one of the
numerous reasons why many doctors have changed to the use of smaller grafts.
Small Grafts vs. Large Grafts
To meet the demand for natural-looking hairlines, doctors began
decreasing the size of grafts in the 1980s. Smaller grafts had the advantage of
being less visible during the transition period after transplantation and before the
hair had grown in. Large grafts placed in a frontal hairline look pluggy and
unnatural when the hair was combed back or to the side. The patient in this
situation was forced to comb his hair forward and down to hide his hairline. When
large grafts are placed behind the hairline or in the crown, they tend to look like
intermittent clumps of hair and are very difficult to disguise.
The amount of time and work needed to place a large number of tiny
grafts is much greater than the time and work needed to place a smaller number
of larger grafts. Smaller grafts also produce a thinner (but more natural)
appearance. If the restoration process is stopped before completion, the patient
will still look natural. Larger grafts tend to obligate the patient to complete
multiple sessions in the quest for natural-looking results and the patient’s
appearance can be strikingly unnatural before the work is completed. Even with
additional work, the large graft transplants often fail to appear natural because
they are intrinsically clumpy. On close inspection, it is literally impossible for
large graft transplants to look and feel natural, even after the best work.
Patients should discuss the size of the grafts and the planned distribution
of the grafts in detail with their surgeons. Some surgeons use larger grafts for the
bulk of the work and then use smaller grafts in an attempt to hide the larger
grafts. Others only transplant small grafts. Some hair transplant surgeons invent
unusual terms for grafts in an attempt to make it appear that they have some
special, unique knowledge or technique. These terms are intended to imply
special variations in graft sizes or an invisible appearance of the grafts. Do not be
confused by arcane terminology. The potential patient should be wary when a
doctor claims to have a unique technology or technique that no other doctor
knows about or uses, unless it is documented and published in a peer-reviewed
medical journal.
Hybrid Grafting Technique
The use of larger grafts for the top and non-central portion of the crown
and smaller grafts for the frontal hairline and perimeter of the transplant has a
variety of names including the Hybrid Technique, Blend Grafting and
Variagrafting. Although this hybrid approach is detectable on close inspection, it
may not be noticeable in a social setting unless the hair is wet or the patient is in
bright sunlight. The results are best in patients who have curly, white or very
blonde hair. Although the look from a distance of two to three feet in soft lighting
may be relatively undetectable, on closer inspection it always is; and it will never
fool the barber.

In individuals with curly or wavy hair, the hybrid approach may be a
reasonable way to reduce the costs of the process. For individuals with straight
hair, such an approach can be disastrous, particularly if the color of the hair
stands out against distinctly contrasting skin tones. The hybrid procedure
generally costs less, and can be performed without the intense labor required for
larger sessions of small grafts. The larger grafts may range from 1.5 mm in size
to more than 2 mm in size. Another disadvantage for those who will accept the
hybrid compromise is that the larger grafts may become more evident when
further balding occurs, particularly when recession allows them to be viewed from
a different angle. The hybrid approach is more a short-term economic solution
than a long-term one and is not recommended by NHI physicians.
Appearance of Hair Transplants
What makes a hair transplant bad is that everyone can tell it is a
transplant. The uneven, patchy effect of the large pluggy grafts occurs when
large grafts are used and the spaces between the grafts are wide. This causes a
contrast between the bald skin and the islands or clumps of hair and creates a
“dolls-head” appearance. Traditional hair transplants also produce small subtle
deformities in the skin. Skin abnormalities with larger grafts occur for two
reasons. First, the surface of the transplanted skin may not be aligned with the
surface of the surrounding scalp (this is seen in larger hair grafts where the
transplanted skin has enough mass to produce the problem). Second, scar
contraction and/or skin dimpling occurs at the recipient site from the healing
process. As the grafts increase in size, these abnormalities occur with increasing
frequency. When the grafts are smaller than the critical size, these problems
rarely exist.
The natural hair mass is composed of hair groupings of one to four hairs
that are close together (follicular units). In nature, only single-hair follicular units
appear at the leading edge of the hairline. To appear natural, a hair transplant
should simulate that look as closely as possible. An ideal hair transplant consists
of follicular units placed closely together with naturally occurring single units
placed at the frontal edge of the hairline. When follicular grafts are placed into
small sites, skin deformities are rare, or nonexistent.
Method of Harvesting Grafts
There are four common methods of harvesting donor grafts. The original
method, devised by Dr. Orentreich, used a hand punch to cut single grafts 4-mm
in size that could contain up to 30 or more hairs. Each punch hole was
separated by small islands of skin. Besides producing very large grafts, there
was hair wastage around the periphery, due to transection and improper angling
of the punch. This method is now rarely used. A second method utilizes a
mechanical punch held in a small hand engine to core out a number of round
grafts of known size. The punch turns at very high speeds; the torque and heat
energy generated by this method will damage the donor grafts.

The donor grafts obtained by the punch
methods can be made into minigrafts by halving or quartering them. The donor
area can then be closed by suturing or can be left open. If the donor sites are
not closed, they develop significant scars. Most doctors have abandoned these
techniques.
The third method uses multiple, parallel scalpels attached together on a
handle, called a multi-bladed knife. Multiple thin strips of hair-bearing donor skin
are removed simultaneously and then grafts of the desired size are cut from the
thin strips of tissue produced by the multi-bladed knife. Using a scalpel does not
produce any torque or heat energy; therefore, no heat or torque damage to the
grafts can occur. This method is quick and simple and still quite popular.
Unfortunately, this method can cause extensive damage to the donor tissue, as it
is impossible to line up the multiple blades parallel to the hair follicles. Because
of this there is unacceptable cutting of individual follicles (transection) and
breaking up of naturally occurring follicular units.
In a fourth method, called single strip harvesting, the donor tissue is
removed as a single strip. The great advantage of this method is that the tissue
is removed from the scalp with the minimal amount of “blind” cutting. The only
blind cutting is the single incision around the periphery of the donor strip as it is
removed. All further dissection can be then performed by direct visualization
using a dissecting stereomicroscope. This keeps potential damage to follicles at
an absolute minimum and allows preservation of intact naturally occurring
follicular units. In order to perform Follicular Unit Transplantation, single strip
harvesting and stereo-microscopic dissection must be used.
Appearance of the Donor Area
Unless the back and side hair is extremely short, the donor area will be
covered by hair and will be unnoticeable after surgery. All donor “harvests” result
in a scar, but if done properly, the scars may become, for all practical purposes,
virtually invisible. Not only is it important for the scar to be closed meticulously,
but also the scar must be placed in the proper position, in the mid-portion of the
donor area. Scars that are place too low have an increased risk of stretching
from the movement of the neck muscles. Scars that are placed very high run the
risk of being visible if there is extensive balding. In addition, the hair that is
obtained from these high incisions may not be permanent.
Re-harvesting the same area is important to keep visible scaring to a
minimum and to keep the donor scar in the mid-portion of the permanent zone.
Some doctors harvest a new area for each surgery. When many surgeries are
done, these patients have a stepladder appearance of the back of the scalp from
the multiple scars. Each scar distorts the hair shafts in either side of the adjacent
skin. This distortion occurs because scars tend to contract. When contraction
occurs, the microscopic structures around the scar are pulled. If different donor
sites are chosen for each hair transplant procedure, the total area for distortion of
the hair follicles becomes quite extensive. Such distortions can affect the
surgeon’s ability to maximize the donor hair supply for more extensive hair
transplant restorations and often limit the surgeon’s ability to keep the donor site
undetectable. The following photographs demonstrate the contrast between

extensive scarring associated with multiple procedures, when donor hair is taken
from different areas for each procedure and a properly placed scar repeated from
the same location.
Scar Improvement
Hair transplant specialists are often confronted with patients whose donor
areas have been severely scarred by an older harvesting method, improper
harvesting techniques, too many surgeries, or, in the rare patient, a large scar
due to the patient’s individual healing tendencies. Frequently when scars occur,
they can be surgically improved. The modification of obvious scarring may be
attempted at the same time as a transplant procedure.
Hairlines
Proper selection of donor sites and graft sizes are extremely important
aspects of the surgery. Design of the hairline andplacement of the recipient sites
are also crucial to an aesthetically successful outcome. Some doctors create the
same standard hairline on every patient. This practice is less than ideal. Natural
hairlines vary from one individual to another as much as facial features do. The
hair transplant specialist must be aware of the spectrum of variations that
normally occur. Few natural hairlines are symmetrical; therefore, one should not
attempt to create a perfectly balanced hairline, as it is distinctly unnatural looking.
Men of European descent with naturally full heads of hair often have receded
corners at the temple or a slightly pointed hairline. Men from the Middle East and
Asia often have wide, flat hairlines with a gentler curve. Men of African descent
tend to have a very straight, flat hairline.
Errors can occur when over-demanding patients or over-aggressive
doctors place the hairline too low on the forehead, or restore the juvenile hairline.
The patient must have an active voice in all decisions concerning the placement
and design of the hairline, but it is up to the physician to educate the patient so
that his decisions will be appropriate in the future as well as the present. Faulty
decisions, once acted upon, will be permanent. The only remedy for a hairline
that has been placed too low is to remove the grafts surgically; a situation that is
better avoided than treated after the error has been made.
Hair and Its Variations
Certain hair types may be more common in certain human groups.
Understanding these characteristics may be critical in anticipating the results one
can expect. African hair is very curly. This single characteristic makes African
hair produce some of the best results in hair transplantation, but the dissection
must be performed with extreme care to avoid damage to the curved follicles.
Most Asian hair is black, coarse and straight, making this hair type the
most difficult when striving for good reconstruction results with traditional hair
transplant techniques, especially when the skin is fair. Korean hair, for example,
requires very small grafts (usually one to two hairs per graft) to produce a natural
look. In fair-haired Caucasians with a low contrast between hair and skin tones,
hair transplant results can be spectacular, as the fair skin and blonde hair color
match closely. Using only naturally occurring individual follicular units will
produce natural results with all hair and skin types.

In addition to the variation of size and character of the terminal hairs in
different areas of the head, hair grows in different directions in different parts of
the scalp. Hair in back of the head grows backward and downward; hair in the
front and top grows forward; hair on the sides of the head grows away from the
middle of the head. The place where they meet in the crown is reflected in the
"cowlick." The art of your surgeon should reflect knowledge of your natural
growth patterns, your hairstyle preferences, and how you want your hair to look
when groomed or un-groomed. To create a natural looking head of hair, the
grafts that go into the recipient area should produce hair that is as close as
possible in consistency and direction to the original hair and should reflect the
various characteristics of both your hair and heritage.
A working knowledge of the nuances of different hair characteristics is
essential in producing an ideal result. Fine techniques are necessary to make
perfect donor grafts that are exactly parallel to the direction of the hair shafts of
the original hair in the transplanted area. Artistry is required to design a hairline
that is appropriate to the size and shape of the patient’s head. Precision must be
employed for the proper placement of the many small grafts.
The Fast Track® Method
The technique of performing a large number of grafts in a single session
was introduced in Brazil at the clinic of Dr. Carlos Uebel in the mid-1980’s. Work
of a similar nature was performed a little later in Austria, Germany, and Japan.
Dr. Uebel's focus was on moving one- to two-hair grafts in quantities of up to
1,500 grafts in a single session.
In 1992, New Hair Institute expanded upon the earlier micrograft
procedures to perform large megasessions of 2,000-3,000 very small 1-3 hair
grafts in a single session and called this the Fast Track® method. The procedure
was popularized worldwide when, in 1994 and 1995, NHI brought several dozen
live patients with their work completed to two conventions of the ISHRS
(International Society of Hair Restoration Surgeons) in the United States and
Canada and showed the results of these megasessions.
The results were so impressive that they put to rest the challenges to
NHI's Fast Track® method and put the "Megasession" permanently on the map.
In 1995, NHI began using only follicular units in these large sessions and called
the procedure Follicular Transplantation. The name was formally changed to
Follicular Unit Transplantation in 1998.
Although Dr. Uebel’s balding patients did not necessarily have the
appearance of full heads of hair, they were able to achieve thin natural heads of
hair in single sessions to frame their faces. They also had the opportunity to stop
after just one session without worrying about an unfinished appearance. The
Fast Track® approach takes these advances a step further and makes the
transplant reconstruction fit into a socially acceptable time period. The most
distinct difference between the Fast Track® and other similar transplantation
procedures is the high number of hair follicles that are moved in naturally growing
follicular units. This dramatically reduces the number of procedures required.
The Fast Track® method may condense the entire hair transplantation
process into one or two surgical procedures. With this approach, each procedure
may stand on its own, and subsequent procedures are simply the decision of the

patient to add additional density or refinement. If more than one procedure is
desired, another can be performed in as little as 8 months, if appropriate. A
second procedure should await the results of the earlier procedure before
reassessing goals and determining the cosmetic effects of the first procedure.
This means that density may be added incrementally, and that the patient may
stop with just one procedure if he chooses to do so and still achieve an attractive
and natural outcome. With the Fast Track® method, the number of surgeries is
minimized, as is the disruption of the patient’s life.

Chapter 7
What is Follicular Unit Transplantation?
What are Follicular Units?
Human hair grows in tiny bundles called follicular units. Although this fact
had been recognized for some time by histologists (doctors who study human
tissue), the existence of follicular units has been largely ignored by physicians
performing hair restoration surgery.
The follicular unit of the adult human scalp consists of 1-4 terminal (full
thickness) hair follicles. In areas of the scalp affected by genetic balding, the
healthy terminal hairs are gradually replaced by hairs of smaller diameter and
length called “miniaturized” hairs.
In addition to the full terminal hairs, the follicular unit contains 1-2 fine
vellus hairs, sebaceous (oil) glands, a small muscle, tiny nerves and blood
vessels, and a fine band of collagen that surrounds the unit (the perifolliculum).
The follicular unit is thus the hair bearing structure of the skin and should be kept
intact to insure maximum growth.
The follicular unit is seen on the surface of the scalp as a tiny group of
hairs that appear to be growing together. They are best viewed under a
microscope where they are seen as well-formed structures in the skin.
What is Follicular Unit Transplantation?
Follicular Unit Transplantation is a technique, pioneered by the physicians
at the New Hair Institute, in which hair is transplanted from the permanent zone
in the back of the scalp into areas affected by genetic balding (and some other
types of hair loss), using only the naturally occurring, individual follicular units. In
order to remove follicular units from the back of the scalp without damaging
them, the donor tissue must be removed in one piece. This technique, “single
strip harvesting,” is an essential component of follicular unit transplantation as it
not only preserves the follicular units, but also prevents damage (transection) to
the individual hair follicles. It differs dramatically from the minigrafting and
micrografting technique of using a multi-bladed knife that breaks up follicular
units and causes unacceptable levels of transection of hair follicles.
Another essential component of Follicular Unit Transplantation is
“stereomicroscopic dissection.” In this technique all of the follicular units are
removed from the donor tissue under total microscopic control to avoid damage.
Complete stereomicroscopic dissection has been shown to produce an increased
yield (as much as 30%) of both the absolute number of follicular units, as well as
the total amount of hair. (This procedure differs from minigrafting and
micrografting in which grafts are cut using minimal or no magnification.)
A major advantage of follicular unit transplantation (besides preserving
follicular units and maximizing growth) is that it allows the surgeon to use small
recipient sites. Grafts comprised of individual follicular units are small because
follicular units are small, and because the surrounding non-hair bearing tissue is
removed under the microscope is not trans-

planted. Follicular unit grafts can be inserted into tiny needle-sized
sites in the recipient area, that heal in just a few days, without leaving any
marks.
When performed by a skilled surgical team, Follicular Unit Transplantation
can produce totally natural-looking hair transplants that maximize the yield from
the patient’s donor supply to give the best possible cosmetic results. Because
the tiny follicular unit grafts (and the very small wounds they are placed in) allow
large number of grafts to be safely transplanted in one procedure, the total
restoration can be completed in the fewest possible sessions.
The Reason for Using Only Follicular Units
The fact that scalp hair grows in follicular units, rather than individually, is
most easily observed by densitometry, a
simple technique whereby scalp hair is clipped short in a very small area and
then observed via magnification in a 10mm2 field. What is very obvious when
one examines the scalp by this method, is that follicular units are relatively
compact, but
are surrounded by substantial amounts of non–hair bearing
skin. The actual proportion of non-hair bearing skin is probably on the order of
50%, so that its inclusion in the dissection (or, conversely, its removal) will have a
substantial effect upon the outcome of the surgery. When multiple follicular units
are used (as in minigrafting and micrografting) the additional skin that is included
will adversely affect the outcome of the surgery, by necessitating larger wounds,
making the healing slower and often causing irregularities of the skin surface.
A great advantage of using individual follicular units is that the wound size
can be kept to a minimum, while at the same time maximizing the amount of hair
that can be placed into it. Having the flexibility to place up to 4 hairs in a tiny
recipient site has important implications for the design and overall cosmetic
impact of the surgery. This is one major advantage that follicular unit
transplantation has over extensive micrografting. Follicular Unit Transplantation
can minimize or eliminate the “see through” look that is so characteristic of
micrografting.
The main reason for transplanting only individual follicular units is to
duplicate the way hair naturally grows. By mimicking the way hair grows in
nature, the doctor can insure that the transplant will look totally natural. Any
grouping larger than the naturally occurring follicular unit will run the risk of a
pluggy, tufted look.
The Importance of Keeping Recipient Sites Small
Using only follicular units enables the recipient sites to be kept very small.
In fact, in Follicular Unit Transplantation, the sites are so small that they are
made with specialized instruments that are the size of 18-20 gauge needles.
This is about the size that is used in routine blood tests.
The importance of minimizing the wound size in any surgical procedure
cannot be over emphasized. This, of course, includes hair transplantation as
well. The effects of recipient wounding impact many aspects of the surgery.
Larger wounds tend to injure larger blood vessels and although the blood supply

of the scalp is extensive, the damage to these vessels can have a deleterious
impact on blood flow to the tissues.
Especially when transplanting large numbers of grafts per session, it is
important to keep the recipient wounds as small as possible so that growth will
be maximized. The compact follicular unit is the ideal way to permit the use of
the smallest possible recipient site, and has made the transplantation of large
numbers of grafts technically feasible. Another important advantage of the small
wound is a factor that can be referred to as the “snug fit.” A follicular unit graft is
so small that it can always fit into a tiny wound without having to remove tissue.
Unlike the punch, which destroys recipient collagen and elastic tissue, a small
incision, made with a needle, retains the basic elasticity (recoil) of the recipient
site. When a properly fitted graft is inserted, the recipient site will then hold it
snugly in place. This “snug fit” has several advantages. During surgery, it
minimizes popping and the need for the sometimes traumatic re-insertion or re-positioning
of grafts. After the procedure, it ensures maximum contact of the
graft with the surrounding tissue, so that oxygenation can be quickly re-established.
In addition, by eliminating empty space around the graft,
microscopic clots are minimized and wound healing is facilitated.
It is important to note that when trying to place larger grafts (either round
or linear), into a small site (kept small to minimize tissue injury) compression of
the grafts is an undesirable consequence, and may result in a tufted appearance.
In contrast, when transplanting follicular units, there are no adverse cosmetic
effects of compression, since follicular units are already tightly compacted
structures.
Finally, large wounds cause a host of other cosmetic problems including
dimpling, pigmentary alteration, depression or elevation of the grafts, or a
thinned, atrophic look. The key to a natural appearing hair transplant is to have
the hair emerge from perfectly normal skin. The only way to ensure this is to
keep the recipient wounds small.
How is Follicular Unit Transplantation Different from Mini-Micrografting?
This is one of the most commonly asked questions and it is a very
important one for those deciding which hair restoration procedure to choose. In
contrast to Follicular Unit Transplantation, where the graft sizes are determined
by nature, in mini-micrografting (the combination of minigrafts and micrografts as
defined in Chapter 6) the graft sizes are arbitrarily determined by the doctor who
cuts the donor tissue into the size pieces that he wants. Another name for this
technique is mini-micrografts “cut to size.”
In mini-micrografting, neither preserving follicular units, nor even keeping
hair follicles intact, are felt to be that important. Rather, the speed and
economics of the procedure are the deciding factors. Mini-micrografters use a
multi-bladed knife to quickly generate thin strips of tissue and then use direct
visualization (rather than microscopic control) to cut the tissue. The resulting
grafts are generally larger than follicular units and since the excess skin is not
trimmed away the donor sites (wounds) are also larger.
It should be apparent from the comparison shown on the next page that
Follicular Unit Transplantation is superior in producing a natural, undetectable
result, in maximizing healing, and preserving precious donor hair. Mini-

micrografting, however, requires a smaller staff and each procedure is cheaper
and shorter (although in the end it takes more procedures and therefore may cost
just as much for this technique).
For more detailed information on NHI’s Follicular Unit Transplantation,
please see the reference section in the back of the book. Many of the original
articles can be found on our web site www.newhair.com in the section, NHI
Medical Publications.
The following table summarizes the major differences between Follicular Unit
Transplantation and Mini-Micrografting:
Follicular Unit Vs Mini-
Micrografting
Transplantation
THE GRAFTS
Follicular Units used exclusively Yes No
Graft size Uniformly small Larger
Number of hairs per graft 1-4 1-6 (or more)
Hair/skin ratio in graft High
Average
Extra skin transplanted No Yes
Wound size Uniformly small
Variable
THE TECHNIQUE
Harvesting type Single-Strip Multi-bladed
knife
Microscopes required Yes
No
Follicular Units Preserved Yes No
Follicular transection No
Yes
Maximizes donor supply Yes No
THE RESULTS
Healing time Fast Slower
Skin surface change No
Yes
Maximum fullness Yes No
Undetectable Yes No
COST & CONVENIENCE
Staff requirements Moderate
Small
Duration of individual procedure Long
Short
Time for complete restoration Short
Long

Cost per procedure More
Less
Total cost for restoration Similar
Similar

Chapter 8
Your Master Plan for Future Hair Loss
Hair restoration is as much an art form as a medical discipline and is best
planned, performed, and completed by the same surgeon or surgeons trained in
using the same techniques. If various surgeons work on the same patient and
different techniques are employed, the results may look more like a patchwork
quilt than a normal head of hair. As with great artists, the best surgeons work
from a Master Plan. They sketch out a plan, project the amount of work needed,
and then implement the plan. In contrast to art, in which the artist has sole
discretion in how the work is created, both the doctor and the patient must
assess the soundness of a Master Plan in a hair restoration process.
If the patient feels the proposed Master Plan is inconsistent with his or her
goals or the course is not consistent with his or her expectations, then the patient
should tell the doctor about his or her concerns. The patient should always feel
comfortable enough to speak his or her mind and expect the doctor to react
responsively. Your doctor should have your best interests in mind, and answer
your questions directly. After the work has been done, it is common for fear and
uncertainty to set in while one waits for the hair to grow in and the final picture to
unfold. It is important for the physician to be supportive and accessible during
this period as well.
Physicians who perform general surgery need little artistic talent to
perform what is, most often, a technical process. In hair transplants, as in other
forms of cosmetic surgery, the work is completely visible. Although the technical
demands of a hair transplant can be substantial, particularly when done in large
numbers, there is no substitute for the skill and experience of the surgeon in
laying out the Master Plan, including creating the hairline, and blending the
various hair characteristics. The artistic ability of the surgeon is best appreciated
by seeing, first hand, the results of his or her work.
The Course of Hair Loss
Most male hair loss is a progressive process in which a person’s full head
of hair inexorably changes to a thinning or receding state and finally to a balding
state. It is common to see the effects of genetic balding in young men start when
they are in their late teens or early 20's. When hair loss occurs early it can be
rapid and quite extensive. More commonly, it is a slow progression, in which the
significant hair loss occurs over a 10-20 year period. The process can start at
any age, possibly even in a person in his 50’s. In the entire male population,
slightly over one-third experience significant balding by the time they reach their
40’s. Fewer than one in eight men become extensively bald (have only a wreath
of hair around the sides and back of the head) by the age of 80.
Genetic hair loss also affects women, but the process rarely leads to the
type of extensive recession or balding frequently seen in men. In genetic hair
loss for either sex, the process accelerates as a person ages and frequently does
so in waves rather than in a continuous fashion. Stress seems to accelerate

short-term loss, but rarely affects the long-term course. There are periods
between the cycles where the hair loss stops for a time (these periods can be
very lengthy in women), but progression is inevitable in all those genetically
predisposed.
Drugs, like minoxidil (Rogaine), may slow the balding process, but are
unsuccessful in completely averting hair loss. Newer medications, such as
finasteride (Propecia) seem to be more successful in preventing further hair loss
on a long-term basis. These drugs may successfully be combined with surgical
hair restoration.
An Individualized Master Plan
Each person is born with a limited supply of hair. Much of the hair around
the side and back of the head may be considered permanent in that it is
genetically programmed to last well into a person’s senior years. This permanent
area of hair, commonly called the "donor area", is where the hair is taken when a
transplant is performed. Hair not located in this region may be susceptible to the
genetic balding process. All surgical hair restoration procedures move hair from
the donor area to areas where the hair is not permanent in genetically affected
people. The permanent hair may be thought of as a "bank" from which
withdrawals are possible, but to which no deposits can be made.
The need for a Master Plan individualized for each patient is critical
because each person has a unique combination of hair density, hair character,
hair color, skin color, balding pattern, age and genetic characteristics. In this
chapter, we will describe the hair loss patterns and hair restoration plans of
several patients with various balding patterns. By studying the specific case
histories, you may gain further insight into your own situation. Although this book
will enable you to gain an understanding of the hair restoration process and the
importance of your Master Plan.
Only an experienced and honest hair restoration physician can customize
your Master Plan to meet your unique needs. Over the past 30+ years, this
industry has not been forthcoming and open in its representations of the results
obtained from the various hair restoration procedures. Much of the lack of
openness still exists. For this reason, the buyer should be wary of dubious
medical claims and patient results that cannot be confirmed.
The Donor Hair Bank
The average Caucasian is born with approximately 100,000 hairs on the
head. Those of Asian and African descent are generally born with lower
densities. If we were to look at the Norwood Class 7 hair loss pattern as the final
stage of hair loss (illustration above), up to 75% of these hairs, or 75,000 will be
lost and 25,000 hairs will remain (permanent hair) in the donor area. A portion of
this permanent hair can be utilized for hair transplantation. A standard rule of
thumb is that, in a person with average hair density, one can deplete the
permanent zone by approximately 50% to 12,500 hairs. Thus, in this Class 7
male, it is generally possible to move some 12,500 hairs or, assuming a normal
distribution of one, two, three and four-hair follicular unit, approximately 5,000-
6,000 follicular unit grafts can be moved.

If the density in the donor area is high (a person born with 150,000 hairs),
the amount of usable donor hair increases significantly. In a person born with
150,000 hairs and in an advanced stage of balding, the donor areas would
contain 37,000 hairs (instead of 25,000 hairs in the average person). Leaving the
required 12,500 hairs in the donor area means that there are some 25,000 hairs
available for transplant. Note that a 50% increase in hair density results in a
100% increase in available donor hair. Unfortunately, the reverse is also true.
Suppose the patient has 75,000 hairs at birth. This means he will have 20,000
hairs in the donor area leaving only 7,500 hairs for transplant. Thus, a 25%
reduction in hair density results in a 50% reduction in available donor hair.
The other key factor affecting the mathematics of the Master Plan involves scalp
laxity (the flexibility and looseness of the scalp). This measurement is a factor in
determining the size of the donor area that may be safely removed in a single
surgical procedure and will determine the total amount of movable hair long-term.
In a patient with a tight scalp, it may be relatively easy to harvest the
needed grafts in the first procedure. However, in subsequent sessions, the tight
scalp may become a significant limiting factor. Such a patient may eventually be
able to move the needed amount of donor hair, but may require several
procedures to accomplish this goal. More commonly, the total amount of
movable hair is reduced in patients with tight scalps and it is important for the
physician to identify this before the surgery is begun so that a realistic long-term
master plan can be established. Certainly, many patients with tight scalps have
very successful transplants, but the expectations of having full coverage might be
unrealistic.
For a single surgical procedure, more hair can be moved when the scalp
is loose and the density is high. Usually in subsequent procedures, scalp laxity
returns to its original state, but eventually it may tighten to reduce the yield with
subsequent procedures. If the laxity returns to its preoperative state, a similar
area can be moved once again, but the density of the hair in that portion of the
scalp will be less, as the skin will have stretched to accommodate the portion
previously removed.
It is important to take into account both hair density and scalp laxity when
we consider the amount of hair that needs to be moved. A bald scalp in the
average Class 6 patient is about 80 square inches (200 cm2). A maximum of
approximately 12 square inches (30 cm2) may be moved from the donor area at
one time, with 9 square inches (24 cm2) being the amount removed in the
average large case of Follicular Unit Transplantation. If a strip of 9 square inches
will have to cover an area of some 80 square inches, if uniformly spaced, this will
produce a density of approximately 12% of the original hair density. This may
not seem like a lot, but if planned properly, the density achieved in the front part
of the scalp can be significantly increased due to the forward weighting of sites
(making them closer together towards the front) and graft sorting (using larger
naturally occurring follicular units in the forelock area). Aesthetic manipulations
of graft placement, performed by experienced hair restoration surgeons can
make dramatic differences in the outcome of the surgery and enable an entire
restoration to be completed in a limited number of sessions. From an aesthetic
perspective, gains from subsequent procedures produce a less dramatic change,
but they have the ability to significantly increase fullness. Thickening a thin head

of hair is less noticeable than going from a balding to a thinning appearance, but
is very important to getting the maximum benefit from your restoration.
At the other end of the spectrum, in a person with early hair loss (a
Norwood Class 3 for example) who simply wanted to fill in the corners of his
hairline to cover an area of 4 square inches, it would be easy to move a piece of
donor scalp from the permanent zone close to the size of the area to be covered.
The new density of this treated area would be much closer to the original density
than the previous example. The most important issue, however, is to project the
future needs of the patient to make sure that sufficient donor hair remains to
address the evolving balding pattern. Great care must be taken so that excessive
amounts of hair are not removed from the donor area to treat the limited
recession, given the possibility that such a patient may need to reserve his donor
hair to cover evolving hair loss.
The average range of follicular unit grafts used per session at the New
Hair Institute is from 600 (for early balding) to 2,400 (for Class 6 and 7 patients).
The average case performed at the New Hair Institute for all stages of balding (all
Norwood Classes) is around 1,500 follicular unit grafts. Since there is
approximately one follicular unit per mm2 in the scalp, a case of 1,500 follicular
units would require 1,500 mm2 of tissue or 15cm2, providing that none of the
donor hair is wasted. A recent retrospective study at the New Hair Institute,
which reviewed cases performed using “single strip harvesting” and “stereo-microscopic
dissection” showed this to be the case. In the average patient, 1
cm2 of donor tissue yielded 100 follicular unit grafts, exhibiting virtually no
wastage.
Some patients express concern about the size of the donor strip that
needs to be harvested from the back of the scalp. In Follicular Unit
Transplantation, a 1,500 graft case would require only a single 1cm wide by 15
cm long strip of donor tissue. This is just slightly larger than the size of a pen.
When considering the donor supply, the most important question for the
patient to ask is "will the technique used to harvest and transplant hair minimize
wastage, so that the maximum degree of fullness may be obtained from a
specific amount of donor hair?” As discussed in Chapter 7, the answer to the
question is that the physician must employ the technique of “single strip
harvesting” when removing the donor tissue followed by “stereo-microscopic
dissection” into individual follicular unit grafts if maximum use of the donor hair
supply is to be achieved.
Aesthetics: The Bottom Line
Restoring your hairline, or increasing the appearance of fullness, is not
purely a reflection of the amount of hair moved, or the number of grafts
transplanted. There is an art in the design of the surgical process that is critical in
producing an aesthetically pleasing result. Some of us are better hair transplant
candidates (more hair, better color, thicker hair shafts, wavier hair); these factors
produce more fullness and better coverage with a smaller quantity of follicular
unit grafts.
It is tempting to try to reduce the Master Plan to a matter of numbers, but
that would be inappropriate. For example, a doctor tells patient that he needs to
move 10,000 hairs in 1,000 grafts in four divided sessions of 250 grafts each.

The Patient's Guide To Hair Restoration

The Patient's Guide To Hair Restoration

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